Recurrent pericarditis (RP) affects 10% to 50% of patients with acute pericarditis. The use of steroids has been associated with increased recurrence rate of pericarditis, along with known major side effects. Cardiac magnetic resonance imaging (CMR) is more frequently used to assess pericardial inflammation and less commonly to guide therapy. The aim of this study was to assess the utility of CMR in the management of RP compared with standard therapy. A total of 507 consecutive patients with RP after the first attack, all of whom were treated with colchicine and nonsteroidal anti-inflammatory drugs as first-line therapy, were retrospectively evaluated. There were 257 patients who were treated with medications and received CMR-guided therapy (group 1) and 250 patients who were treated with medications without CMR (group 2). The 2 groups had similar baseline characteristics and follow-up periods (17 ± 7.9 vs 16.3 ± 16.2 months, respectively, p = 0.97). CMR was used to assess the presence of pericardial inflammation, and on the basis of the results, the clinician made changes to the steroid dose dictated by the severity of inflammation. There was no significant difference in the incidence of constrictive pericarditis, pericardial window, or pericardiectomy between groups during the follow-up. However, group 2 patients had a larger number of steroid pulse therapies (defined as prednisone 50 mg/day orally for 10 days and tapering to none over 4 weeks), and higher overall total milligrams of steroid administered compared with the CMR group (p = 0.003 and p = 0.001, respectively). Recurrence and pericardiocentesis rates were lower in group 1 (p <0.0001). In conclusion, CMR-guided therapy modulates the management of RP. This approach decreased pericarditis recurrence and exposure to steroids.